Emergency Department Screening Identifies Many Patients With Possible Eating Disorders, Suggesting Potential to Facilitate Earlier Diagnosis and Connection to Treatment

Service Delivery Innovation Profile

Emergency Department Screening Identifies Many Patients With Possible Eating Disorders, Suggesting Potential to Facilitate Earlier Diagnosis and Connection to Treatment

Snapshot

Summary

As part of a broader research initiative, the University of Michigan Medical Center emergency department asks patients to complete a five-question electronic survey that screens for eating disorders as they await treatment. To date, research assistants have taken on the role of identifying eligible individuals (typically all patients in a particular age range), explaining the program, securing consent to participate, and administering and scoring the electronic survey. (If conducted outside of a research study, department-based staff would perform these roles.) The survey has identified a significant proportion of patients who screen positive (much higher than in the general population), with positive screens being particularly common among frequent emergency department users. These findings suggest that this venue can be an effective venue for early diagnosis and connection to needed support for those with eating disorders. Going forward, program leaders plan to test this potential by evaluating an expanded project that will provide emergency department–based support for those who screen positive, possibly including a brief educational intervention and referrals to community-based providers and programs that specialize in eating disorders.

Evidence Rating

Suggestive: The evidence consists of the proportion of positive screens for eating disorders among those screened by this program (including for the subset of patients who are frequent ED users), compared to the prevalence of such disorders in the general population of individuals in the same age range.

Date First Implemented

2010

Use of the survey began on October 15, 2010, as part of a broader screening effort among emergency department patients ages 14 to 20 years; a similar survey is currently being tested with those between the ages of 21 and 64 years.

Problem Addressed

Eating disorders are often not diagnosed until long after they manifest, making it more difficult to successfully treat them. Emergency departments (EDs) may be an effective venue for identifying those with potential eating disorders and connecting them to resources that can help, but few EDs play this role today.

  • Late diagnosis: Though individuals with eating disorders tend to access health care services more frequently than the typical person, providers often do not recognize that their complaints (e.g., fatigue, abdominal pain, constipation, amenorrhea, fainting spells) may be signs of an eating disorder, and hence the condition can remain undiagnosed for years. In many cases, patients end up being referred to specialists (e.g., gastroenterologists, gynecologists) who conduct extensive diagnostic evaluations that do not include screening for an eating disorder.1
  • Leading to poorer outcomes: The likelihood of successful treatment of an eating disorder declines the longer the disorder remains undiagnosed.2 , 3
  • Unrealized potential of ED: Individuals with eating disorders disproportionately use EDs and urgent care centers, making such settings a potential opportunity to screen for the condition and connect those who screen positive to treatment and support. However, few EDs routinely screen patients for these disorders.4 , 5 , 6

Description of the Innovative Activity

As part of a broader research study, ED patients at the University of Michigan Medical Center complete a five-question electronic survey that screens for eating disorders as they await treatment. To date, researchers have taken on the role of identifying eligible patients, explaining the program, securing consent to participate, and administering and scoring the survey. (If conducted outside of a research study, department-based staff would perform these roles.) Going forward, the research team plans to test an expanded version of the program that will provide support for those who screen positive, possibly including brief ED-based education and referrals to community-based programs. Key program elements are outlined below:

  • Identifying eligible patients: During research trials, a research assistant identifies eligible patients by observing the electronic whiteboard and identifying those within the age range being targeted. After obtaining informed consent, the assistant screened all patients ages 14 to 20 years for the initial study; an ongoing study screens all patients ages 21 to 65 years. Outside of a research study, ED-based staff (e.g., administrative staff, nurses, physician assistants) could play this role.
  • Explaining program and securing consent: After the patient has been moved to a private room, the research assistant explains the purpose and benefits of screening to eligible patients and obtains their written consent to be screened. For those younger than 18 years, the research assistant obtains parental consent for the son or daughter to complete the survey. Outside of a research study, ED-based staff (likely nurses or physician assistants) would play this role.
  • Completing survey: The research assistant hands the patient a tablet computer that contains the survey questions. (Outside of a research study, ED-based physicians or nurses would likely play this role, either providing a tablet-based survey or asking the questions verbally as part of the normal information-gathering process.) Each patient completes a series of five yes-or-no questions that screen for eating disorders, with the typical patient taking just a few minutes to answer them. (During the research trials, the eating disorder questions represent one part of a longer survey that also focuses on alcohol abuse; the entire survey takes just under 20 minutes to complete.) Modified and adapted to the ED setting from an empirically validated screening tool for eating disorders commonly used in the United Kingdom in primary care (known as SCOFF, a mnemonic that comes from the wording of the questions in the original survey), the five survey questions used in the ED are as follows1 :
    • Do you ever make yourself throw up (or use laxatives, water pills, or exercise) because you feel uncomfortably full?
    • Do you worry you have lost control over how much you eat?
    • Have you recently lost or gained more than 10 to 15 pounds in a 3-month period?
    • Do you believe yourself to be too fat when others say you are too thin?
    • Do thoughts and fears about food and weight dominate your life?
  • Scoring survey to identify those with suspected disorder: The research assistant scores the survey, with any person answering yes to two or more questions being considered a positive screen, suggesting that they may have an eating disorder. (The instrument does not provide a definitive diagnosis.)
  • Future plans to offer additional support: At present, the research staff does not intervene with patients who screen positive, although everyone who completes the longer survey receives a list of community-based resources for alcohol abuse and eating disorders. Going forward, program leaders hope to implement and test an expanded version of the program that would offer additional support. Although details have not yet been finalized, this support would likely include informing the individual of the positive screen, providing brief ED-based education (including encouraging the patient to seek further evaluation), and distributing a list with information about relevant community-based providers and resources.

Context of the Innovation

Part of the University of Michigan Health System, the University of Michigan Medical Center consists of an adult hospital, a children's hospital, a women's hospital, a comprehensive cancer center, a cardiovascular center, an outpatient health care center, a center for medical education, a hotel for patients and families, a medical school, and a medical library. The medical center has 900 licensed beds, 60 onsite operating rooms, 2 ambulatory surgical centers, and 3 EDs (adult, children's, and psychiatric). In fiscal year 2011, it handled 44,864 inpatient discharges, 46,054 surgical cases, 1.8 million outpatient visits, and more than 100,000 ED visits.

The impetus for this portion of the broader screening program (see the Planning and Development Process section below for more details) came from Suzanne Dooley-Hash, MD, an emergency medicine physician who has a long-standing interest in eating disorders. Dr. Dooley-Hash noticed that many younger patients, particularly teenage girls, came into the ED with symptoms that could be indicative of an underlying eating disorder, such as fainting spells and belly pain. She felt that identifying these youth in the ED could prevent potential poor outcomes later.

Dr. Dooley-Hash and several colleagues worked collaboratively to develop and test this screening initiative. These colleagues include: Rebecca Cunningham, MD, from the Department of Emergency Medicine at the University of Michigan and the Department of Emergency Medicine at the University of Michigan Injury Center; Maureen Walton, MPH, PhD, from the Department of Psychiatry at the University of Michigan; Yarden Ginsburg, MS, also from the Department of Psychiatry at the University of Michigan; and Judith Banker, MA, LLP, FAED, from The Center for Eating Disorders in Ann Arbor, MI.

Results

The program identified a significant proportion of patients who screened positive for a potential eating disorder (much higher than in the general population), with positive screens being particularly common among frequent ED users. These findings suggest that the ED can be an effective venue to screen for eating disorders, with the potential to facilitate earlier diagnosis and connection to community-based treatment and support than would otherwise occur.

  • High proportion of positive screens compared to general population: Overall, approximately 16 percent of patients ages 14 to 20 years screened positive for an eating disorder, well above the roughly 2 to 5 percent rate for those of a similar age range in the general population.7 Because the screening tool does not provide a definitive diagnosis, program leaders estimate that 10 to 20 percent of those identified will end up being false-positives, meaning that the true prevalence might be just under 13 percent (still well above the rate found in the general population). Early findings from a second study targeted at those ages 21 to 65 years suggest a similar prevalence. In the absence of this program, the condition may remain undiagnosed and therefore untreated, in these individuals for months or years.
  • Even higher prevalence among frequent ED users: The likelihood of a positive screen was particularly high among frequent ED users, which further underscores the potential value of the ED as a venue for screening. Overall, patients screening positive were 1.6 times more likely to have visited the ED in the past year than those who did not. Among those who had visited the ED five or more times in the past year, 43.3 percent screened positive for an eating disorder.1

Evidence Rating

Suggestive: The evidence consists of the proportion of positive screens for eating disorders among those screened by this program (including for the subset of patients who are frequent ED users), compared to the prevalence of such disorders in the general population of individuals in the same age range.

Planning and Development Process

Key steps included the following:

  • Piggybacking on larger study: As a research institution, the medical center regularly conducts various projects to test care delivery innovations. Dr. Dooley-Hash was aware of an ongoing project being conducted by her colleagues that focused on ED-based screening and intervention for risky health behaviors. She approached them about adding a few eating disorder questions to their screening instrument.
  • Modifying existing survey: Dr. Dooley-Hash researched available screening surveys and identified SCOFF, which had demonstrated acceptable validity in studies conducted in the United Kingdom. She made minor modifications to the questions, primarily to adapt the language to American culture (e.g., changing “stones” as a measure of weight to “pounds”). She also expanded the question about rapid weight loss to incorporate weight gain, which can also be a sign of an eating disorder.
  • Securing approval: Dr. Dooley-Hash briefed her colleagues on plans to include the eating disorder questions as part of the ongoing project. The larger project received approval from relevant department heads and the medical center's Institutional Review Board.
  • Conducting screening-only trials: As noted, the first trial focused on those ages 14 to 20 years, and a second ongoing trial targets those ages 21 to 64 years. Both trials incorporate only the screening component (i.e., the five-question survey) to see if the ED represents an effective venue to identify those with potential eating disorders.
  • Pursuing funding to test expanded program: Dr. Dooley-Hash is applying for additional funding to test the utility of an expanded ED-based screening and referral program, as described earlier.

Resources Used and Skills Needed

  • Staffing: As noted, the program thus far has used research assistants to identify eligible patients, enroll them, and administer and score the survey. Outside of a research study, existing ED-based staff would incorporate program-related activities into their regular job responsibilities.
  • Costs: Outside of research-related expenses, program costs are minimal.

Funding Sources

The National Institute on Alcohol Abuse and Alcoholism supported this research study through a grant (AA018122).

Tools and Resources

The SCOFF survey questions (as modified for this project) have been published in:
Dooley-Hash S, Lipson SK, Walton MA, et al. Increased emergency department use by adolescents and young adults with eating disorders. Int J Eat Disord. 2013;46(4):308-15. [PubMed]

Getting Started with This Innovation

  • Use or adapt existing survey: As noted, SCOFF has been tested and represents a good screening survey that can be tweaked to meet local circumstances and needs.
  • Conduct pilot test to determine magnitude of problem: Few ED-based providers believe that ED patients are disproportionately at risk of eating disorders, and hence do not believe it is important to screen for them systematically. To overcome this perception, conduct a brief pilot test to see if screening identifies a high proportion of patients with potential eating disorders.
  • Target those most at risk: In an ideal world, ED-based screening should likely target everyone between the ages of 12 and 40 years, as those in this age range are most likely to have an eating disorder. If adequate support does not exist to screen so broadly, consider screening only those who use the ED frequently or that come in with complaints that could relate to eating disorders (e.g., fainting, belly pain, vomiting blood).

Sustaining This Innovation

  • Monitor and report on program impact: ED-based providers will maintain their enthusiasm for screening if they see evidence that it has a positive impact. To that end, the program would ideally monitor and report on key metrics of the program's success on a regular basis, such as the proportion of patients screening positive and referred to community-based treatment and support, the proportion that access such support, and future ED use among those who do.
  • Make providers aware of available resources: ED-based providers tend to be familiar with community-based substance abuse treatment programs, but often lack knowledge about available resources for eating disorders. Consequently, program leaders must keep abreast of these resources and educate ED-based clinicians about them on a periodic basis.

Contact the Innovator

Note: Innovator contact information is no longer being updated and may not be current.

Suzanne Dooley-Hash, MD
Department of Emergency Medicine
University of Michigan
1500 E. Medical Center Drive
TC-B1-382S
Ann Arbor, MI 48109
E-mail: sldh@med.umich.edu



Innovator Disclosures

In addition to the organizations listed in the Funding Sources section, Dr. Dooley-Hash reported two professional relationships relevant to the work described in this profile: serving as the medical director and providing medical care on a voluntary basis at the Center for Eating Disorders (a nonprofit eating disorder treatment facility in Ann Arbor, MI) and being a volunteer member of the board of the Binge Eating Disorder Association.

References/Related Articles

Dooley-Hash S, Lipson SK, Walton MA, et al. Increased emergency department use by adolescents and young adults with eating disorders. Int J Eat Disord. 2013;46(4):308-15. [PubMed]

An opportunity to spot hidden problems—teen ER patients with eating disorders. Medical News Today. 2012 Nov 21. Available at: http://www.medicalnewstoday.com/releases/253009.php.

Dooley-Hash S, Banker J, Walton M, et al. The prevalence and correlates of eating disorders among emergency department patients aged 14-20 years. Int J Eat Disord. 2012;45(7):883-90. [PubMed]

Footnotes

  1. Dooley-Hash S, Lipson SK, Walton MA, et al. Increased emergency department use by adolescents and young adults with eating disorders. Int J Eat Disord. 2013;46(4):308-15. [PubMed]

  2. Treasure J, Russell G. The case for early intervention in anorexia nervosa: theoretical exploration of maintaining factors. Br J Psychiatry. 2011;199:5-7. [PubMed]

  3. Mitchell J, Agras S, Wonderlich S. Treatment of bulimia nervosa: where are we and where are we going? Int J Eat Disord. 2007;40:95-101. [PubMed]

  4. Striegel-Moore R, DeBar L, Wilson G, et al. Health services use in eating disorders. Psychol Med. 2008;38:1465-74. [PubMed]

  5. Striegel-Moore R, Dohm F, Kraemer H, et al. Health services use in women with a history of bulimia nervosa or binge eating disorder. Int J Eat Disord. 2005;37:11-18. [PubMed]

  6. Striegel-Moore R, Dohm F, Wilfley D, et al. Toward an understanding of health services use in women with binge eating disorder. Obes Res. 2004;12:799-806. [PubMed]

  7. An opportunity to spot hidden problems—teen ER patients with eating disorders. Medical News Today. 2012 Nov 21. Available at: http://www.medicalnewstoday.com/releases/253009.php.

Funding Sources

National Institute on Alcohol Abuse and Alcoholism

Developers

University of Michigan Medical Center
Original Publication: 11/20/13

Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last Updated: 11/20/13

Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read Health Care Innovations Exchange Disclaimer.

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